HospitalInspections.org

Based on review of emergency services policies, medical staff bylaws, on-call roster, and staff interview, the hospital failed to ensure a system was in place to ensure availability of the the physicians on-call for patients in the emergency department (ED) to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The call list lacked the names of the specific physicians with the on-call responsibilities for the day. Instead the list included only the physician practice groups responsible for providing on-call physicians if needed. Some of the physician practice groups' listing includes a list of physicians and their contact information but lacked information identifying which of the physician was responsible for on-call on a specific date.

The hospital administrative staff identified an average of 1,811 patients presenting to the ED requesting emergency care per month.

Failure to maintain a list of the specific on-call physicians available for consultation for ED patients could potentially result in patients not receiving an appropriate evaluation and/or a delay in stabilizing treatment for their emergency medical conditions.

Findings include:

1. Review of on-call schedules dated from 6/1/2014 to 10/31/2014, posted in the Emergency Department, revealed the posted on-call schedules did not identify the specific on-call physicians for Midwest Gastroenterology, Omaha Nephrology, Midwest Eye Care, and other specialty groups. Under the heading for these groups, there was no physician identified or there was a list of physicians with their contact information. The following examples illustrate the problems with the on-call list for 9/22/14 include the following.

a. Under the Midwest Gastroenterology group for 9/22/14, there were two phone numbers listed but there no physicians listed.

b. Under Omaha Urology for 9/22/14, nine different physicians were listed with their names and contact information but the list did not identify which physician was on-call.

c. Under Midwest Eye Care, 14 physicians were listed with their names and contact information but the list did not identify which physician was on-call.

2. During an interview on 11/13/14 at 1:25 PM, Staff A, Vice President of Patient Safety & Quality, acknowledged the posted on-call schedules did not include the specific names of on-call physicians for Midwest Gastroenterology, Second Orthopedic Group, Omaha Nephrology, Midwest Eye Care, Vascular Surgery MHS, Vascular Surgery UNMC, Urology or Neurosurgery specialties. Staff A stated the ED staff would call the answering services for the above mentioned specialties and the answering service would connect the ED with the physician on-call.

During an interview on 11/13/14 at 1:40 PM, Staff C, House Supervisor, stated Midwest Gastroenterology has at least 30 physicians in the group and that group provided on-call services to the hospital. Staff C stated if a gastroenterologist needed to be contacted, the hospital called Midwest Gastroenterology answering service and the answering service would page the physician on-call for the hospital. The physician on-call for the hospital would then call the hospital.

During an interview on 11/13/14 at 1:45 PM, Staff B, ED Manager, stated the ED staff never knew the specific physician on-call for Midwest Gastroenterology. Staff B stated the ED staff contact the Midwest Gastroenterology answering service for the physician on-call for that group. Staff B further stated the Second Orthopedic group has a separate calendar and the ED staff have to go through their answering service to reach the on-call physician.

Based on review of policy/procedure, medical record documentation, and staff interviews, the hospital failed to provide a complete medical screening examination (MSE) for 1 of 40 sampled patients who presented to the hospital's Emergency Department (ED) requesting emergency care for 1 of 40 patient records reviewed between August 1, 2014 through 10/31/2014 (Patient # 25). The hospital administrative staff identified an average of 1811 patients presented to the emergency department requesting emergency care monthly.

Failure to provide a complete medical screening examination in the ED for patient requesting emergency care could result in staff providing inadequate care or ineffective care to treat the emergency medical condition (EMC) and result in decline of the patient's condition.

Findings include:

1. Review of hospital policy titled "Emergency Medical Screening, Treatment, Transfer, & On-Call Roster", dated 1/12, revealed in part, ". . . The objective of the MSE is to determine whether an EMC exists. Once the MSE is completed and it is determined that the individual presented for a non-emergency purpose, the Hospital's EMTALA obligations end for that individual. The scope of an individual MSE depends upon presenting symptoms. The scope of the MSE may range from a simple process involving only a brief history and physician examination to a complex process involving ancillary studies and procedures, such as clinical laboratory tests, CT scans and other diagnostic tests and procedures. The MSE is an ongoing process in many cases and may require documentation for continued monitoring and evaluation. . . ."

Review of Medical Staff Rules & Regulations revealed in part, ". . . Any individual who presents to the hospital and on whose behalf medical examination or treatment is requested, shall receive a medical screening examination, treatment, stabilization and transfer (if appropriate) in accordance with applicable laws and regulations. . . ."

2. Review of Patient #25's medical record revealed the patient returned to the ED on 9/23/14 at 6:00 AM with gastrointestinal bleeding. The patient was previously in the ED on 9/22/14, arriving at 9:13 PM and was discharged home on 9/23/14 at 1:24 AM.

3. The patient returned to the ED later on 9/23/14 at 6:00 AM after experiencing more gastrointestinal bleeding.

ED physician A documented the following information. The patient presents with rectal bleeding. The onset was just prior to arrival. Rectal bleed: grossly bloody. Risk factors consist of had colonoscopy with polypectomy yesterday afternoon. Prior episodes: was in ED earlier this night, given a liter of saline and observed for a while and had CT abdomen (which was okay) and was doing well and discharged home about 1:00 AM. The patient passed more bright red blood but not as much as he did the first time; also having some mild abdominal discomfort and some dizziness but not as bad as before.
- Review of symptoms: Gastrointestinal symptoms: Rectal bleeding. Neurological symptoms: dizziness.
- Vital signs: Blood pressure 130/60, heart rate 85, respirations 16.
- Laboratory results: WBC 8.8, Hbg 13.5, Hct 39%
- Diagnosis: Lower gastrointestinal bleeding - post polypectomy
- Calls - Consults: 9/23/14 at 5:30 AM - Physician C, Gastroenterology, called in to say the patient was returning and that he should be admitted to the hospitalist service so they could scope him later today and cauterize the bleeding site.
- Patient admitted to observation.

4. During an interview on 11/12/14 at 5:00 PM, Staff D, ED Triage RN, stated when patient #25 arrived to the ED on 9/22/14 at 9:13 PM he was taken to the triage room for initial vital signs, obtain information related to medications, allergies, weight. Staff D reported the patient presented with complaint of rectal bleeding and during the triage process the patient complained of feeling faint and appeared pale. Staff D stated the patient was taken to an emergency room and the patient stated he felt nauseous and had a large emesis of liquid with some undigested food. The patient then had a 20 second episode of unresponsiveness. Staff D stated she called ED physician A to the patient's bedside. Staff D stated after the patient's unresponsiveness, the patient was clammy and pale but was alert and oriented. Staff D stated the patient's clothes were removed to clean him up after his emesis. Staff D stated the patient's underwear were not removed and she did not see any evidence of blood in the wheelchair when the patient was transferred to the ED bed from the wheelchair. Staff D stated she did not assess the patient for rectal bleeding.

During an interview on 11/13/14 at 7:10 AM, ED physician A stated the following after reviewing patient #25's ED records for 9/22/14 9:13 PM ED visit and 9/23/14 6:00 AM ED visit. Physician A stated when the patient presented to the ED on 9/22/14 at 9:13 PM the patient was diaphoretic, cool and clammy and complained of rectal bleeding following a colonoscopy with polyp removal earlier in the day. Physician A stated the patient responded to IV fluids during the ED visit and was stabilized. Physician A stated he ordered laboratory tests and a CT of the abdomen which showed nothing acute. Physician A stated his documentation of History of Present Illness including rectal bleed grossly bloody was mostly subjective. Physician A stated he did not perform a rectal exam, the patient had obvious bleeding in the toilet. Physician A stated the determination of the amount of rectal bleeding was mostly subjective. The patient's potassium was 3.0 and oral replacement was ordered and a dose given in the ED. Physician A stated he called Gastroenterology for consult. The patient wanted to go home and gastroenterology said it was okay to discharge the patient to home. The patient was discharged home on 9/23/14 at about 1:00 in the morning.

ED Physician A reported the patient returned to the ED at 6:00 AM on 9/23/14 with another episode of rectal bleeding. The gastroenterology physician called the ED prior to the patient's arrival and we had an order to admit the patient. The patient's blood count was still good when he returned to the ED. The patient was not in distress like he was at the earlier ED visit - his blood pressure was better. Physician A stated he did not perform a rectal exam during the second ED visit as the patient was already to be admitted. Physician A stated he documented the patient's rectal bleed as grossly bloody during both ED visits but acknowledged he did not know if the patient had any clots, the complaint was subjective.

ED Physician A stated during the patient's first ED visit the patient was doing well, the gastroenterology physician said it was okay to discharge the patient if the patient was doing well and the patient wanted to go home. During the first ED visit, we observed the patient a few hours and it was reasonable to discharge the patient.